BMJ Open: first published as 10.1136/bmjopen-2013-003335 on 19 August 2013. Downloaded from http://bmjopen.bmj.
com/ on November 20, 2020 at Helsebiblioteket gir deg tilgang til BMJ.
Open Access
To cite: Johnsen AS,
Fattah S, Sollid SJM, et al.
Impact of helicopter
emergency medical services
in major incidents: systematic
literature review. BMJ Open
2013;3:e003335.
doi:10.1136/bmjopen-2013-
003335
▸ Prepublication history for
this paper is available online.
To view these files please
visit the journal online
(http://dx.doi.org/10.1136/
bmjopen-2013-003335).
Received 2 June 2013
Revised 11 July 2013
Accepted 16 July 2013
1
Department of Research and
Development, Norwegian Air
Ambulance Foundation,
Drøbak, Norway
2
Department of Health
Studies, Faculty of Social
Sciences, University of
Stavanger, Stavanger, Norway
3
Department of
Anaesthesiology, Oslo
University Hospital, Oslo,
Norway
4
Anaesthesia and Critical Care
Research Group, Faculty of
Health Sciences, University of
Tromsø, Tromsø, Norway
5
Department of
Anesthesiology and Intensive
Care, Akershus University
Hospital, Lørenskog, Norway
Correspondence to
Dr Anne Siri Johnsen;
anne.siri.johnsen@
norskluftambulanse.no
Johnsen AS, Fattah S, Sollid SJM, et al. BMJ Open 2013;3:e003335. doi:10.1136/bmjopen-2013-003335
Impact of helicopter emergency medical
services in major incidents: systematic
literature review
Anne Siri Johnsen,1,2,3 Sabina Fattah,1,4 Stephen J M Sollid,1,2 Marius Rehn1,2,5
ABSTRACT
Introduction: Helicopter emergency medical services
(HEMS) aim to bring highly specialised crews to the
major incident for triage, treatment and transport.
When the site is difficult to access, HEMS may be the
only mode of transportation of both personnel and
patients. This systematic review will identify, describe
and appraise literature regarding the role of HEMS in
medical response to major incidents. We aim to
improve knowledge on HEMS role in a major incident
and provide a basis for future research.
Methods and analysis: A systematic literature review
will be conducted with search phrases that combine
HEMS and major incidents to identify when and how
HEMS have been used. Included literature will be
subject to quality appraisal and data extraction.
Ethics: No ethical approval is sought because this is a
literature review. It will be submitted to a peer-reviewed
journal and the PRISMA guidelines will be followed.
Registration details: PROSPERO CRD42013004473
INTRODUCTION
A major incident is any incident where the
location, number, severity or type of casualties
requires extraordinary resources.1 In 2011, an
estimated 332 natural disasters killed over
30 000 people, affected more than 240 million
people and caused economic damages for
over US$300 billion, with the Tohoku earth-
quake and tsunami in Japan being the most
expensive natural disaster ever recorded.2
Helicopter emergency medical services
(HEMS) aims to bring a highly specialised
crew to the incident for triage, treatment and
provide a time-efficient way of transporting
patients directly to trauma centre for definitive
care.3 4 When the site is difficult to access,
HEMS may be the only mode of transportation
that is viable for both personnel and
patients.4 5 The triage system in use has to be
valid and reliable to prevent both overtriage
and undertriage.6 7 When specially trained
personnel perform the triage, hospitals may
avoid reaching their surge capacity.6–10 The
HEMS crew may also provide an overview of
Protocol
ARTICLE SUMMARY
Article focus
▪ We aim to identify, describe and appraise rele-
vant literature regarding the role of helicopter
emergency medical services (HEMS) in medical
response to major incidents.
Key message
▪ Collecting and reviewing data from previous
experiences may improve the role of HEMS in
medical response to major incidents.
Strengths and limitations of this study
Protected by copyright.
▪ The major strength of this article is that it is a
systematic literature review.
▪ The main limitation is that only English and
Scandinavian languages are included.
in-hospital resources, thereby increasing the
probability of getting the right patient to the
right place in the right time.11 However,
HEMS crew combinations may differ from
country to country.12
In previous literature, death and disease
have been the most common outcomes evalu-
ated, while discomfort, disability, dissatisfaction
and depth (cost) were infrequently mea-
sured.13 Earlier reviews have tried to deter-
mine whether HEMS, compared to ground
emergency medical services (GEMS), improve
mortality and morbidity, although morbidity
was difficult to assess.3 14 A meta-analysis on
the percentage of HEMS patients transported
with non-life-threatening injuries has been pre-
formed.15 Other reviews, with non-systematic
design, have aimed to determine outcomes in
literature,16 17 identify patients that will benefit
from HEMS,18 costs19 and survival benefits.20
Assessment of results is difficult because of the
heterogeneity of literature.
This systematic review will identify, describe
and appraise literature regarding the role of
HEMS in medical response to major incidents.
We aim to improve knowledge on HEMS role
in a major incident and provide the basis for
future research.
1
 BMJ Open: first published as 10.1136/bmjopen-2013-003335 on 19 August 2013. Downloaded from http://bmjopen.bmj.com/ on November 20, 2020 at Helsebiblioteket gir deg tilgang til BMJ.
Open Access

Box 2 Different terms and characteristics that will be

Box 1 Quality appraisal extracted from the included articles.

Internal validity (yes, no, not applicable) Data extraction—does the included literature report the following:
Is the author a person directly involved in the major incident Pre-incident data on affected area
medical response? ▸ Basic information on affected area?
Does the literature provide reference to where the data were ▸ Basic information on affected population?
obtained? ▸ Accessibility in the region?
Does the literature provide reference to how the data were ▸ Other preincident data on the affected area?
obtained? Helicopter emergency medical services (HEMS) characteristics
Do the authors have conflicts of interest? ▸ Population covered by HEMS?
Has an ethics committee approved the reporting? ▸ HEMS service area?
External validity ▸ Type of helicopter?
Does the literature describe the local emergency medical ser- ▸ Crew combination
vices (EMS) and helicopter emergency medical services – In everyday operations?
(HEMS) structure before the incident? – During a major incident?
Is the major incident clearly described? ▸ Operating hours?
Are the medical resources used in the major incident response ▸ Previous experiences with major incidents?
clearly described? ▸ Other HEMS characteristics?
Does the literature report the type, number and capacity of Incident characteristics
HEMS? ▸ Time, date and place?
Are there indications on missing data? ▸ Description of incident and the damage it caused?
Are other limitations discussed? ▸ Number of dead?
Is the study design clearly explained? ▸ Number of injured
– Severely, moderately, slightly?
▸ Total number of victims involved?
▸ Scene access?
METHODS ▸ Distance to hospitals?

Protected by copyright.
Study selection ▸ Other incident characteristics?
Search terms include ‘Air Ambulance’ AND ‘Major Incident response
Incidents’ (see additional file I for search strategy). The ▸ How the major incident was declared?
search will include papers published in the period from ▸ The timeline for the medical response?
1946 to date of search. ▸ Who participated
Databases: – Personnel (health, fire, police, military)?
▸ MEDLINE – Transports?
▸ EMBASE – Voluntary organizations?
▸ Cochrane ▸ What tasks they preformed?
▸ Which prehospital resources were lacking?
▸ Web of Knowledge
▸ Prehospital surge capacity?
▸ Swemed ▸ Patient logistics?
▸ Norart ▸ Hospital surge capacity?
▸ Scopus ▸ HEMS
▸ CINAHL – Number of crews involved?
▸ PsycINFO – Time from alarm to arrival at scene?
Grey literature will not be included. Previous experi- – Information received from scene and ambulance dispatch centre?
ence has shown that this generates a large workload – Did they bring extra crew?
without results.21 – Did they bring extra equipment?
Inclusion criteria: – Number of patients transported by HEMS?
▸ Literature describing the role of HEMS in medical – Which hospitals received the patients?
– Were other responsibilities described?
response to major incidents.
– Were other tasks preformed?
▸ Original manuscripts. ▸ Communication?
Exclusion criteria: ▸ Scene safety?
▸ Articles in languages other than English and ▸ Other incident response data?
Scandinavian. Patient characteristics
▸ Articles without abstract. ▸ All age groups involved?
▸ Book chapters. ▸ Classification of injury?
▸ Letters to the editor, comments and editorials. ▸ Triage at first evaluation?
One author (ASJ) will scan titles and abstracts and ▸ Triage before transport?
exclude articles clearly not meeting the inclusion cri- ▸ Injury score reported?
teria. Uncertain articles based on abstract will be sub- ▸ Medical illnesses reported and classified?
▸ Other patient characteristics?
jected to consensus among all the authors. The
Other relevant information reported?
remaining articles will be derived in full-text and divided

2 Johnsen AS, Fattah S, Sollid SJM, et al. BMJ Open 2013;3:e003335. doi:10.1136/bmjopen-2013-003335

among the authors in pairs (ASJ and MR, SF and SJMS)
and screened further for eligibility according to inclu-
sion and exclusion criteria listed above. The articles
excluded in this phase will be listed with reason in the
final article. Reference lists of included literature will be
scanned to identify relevant literature. Authors of
included articles with email listed will be contacted if
necessary. ASJ will perform a quality appraisal (box 1) to
depict the internal and external validity of the literature
at hand and extract pre-defined data from included arti-
cles. Data extraction (box 2) will aim to describe the
incident background and how HEMS contribute on the
scene of the major incident with resources and transpor-
tation. Data extraction variables will be entered into a
template22 (box 2) which has been pilot tested on four
randomly selected articles. The results of quality
appraisal and data extraction will be double-checked by
another author. Included articles will be described sep-
arately, but articles describing the same major incident
will be compared and grouped.
Acknowledgements Marie Isachsen, Ullevål University Hospital Library, Oslo,
Norway, designed and will conduct the literature search.
Contributors ASJ and MR conceived the idea. All authors were part of the
study design. ASJ, SF, SJMS and MR wrote the manuscript. All authors have
approved final version of the protocol.
Funding The Norwegian Air Ambulance Foundation (NAAF) employs all
authors. However, the NAAF played no part in study design, data collection,
analysis, writing or submitting to publication.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.
Open Access This is an Open Access article distributed in accordance with
the Creative Commons Attribution Non Commercial (CC BY-NC 3.0) license,
which permits others to distribute, remix, adapt, build upon this work non-
commercially, and license their derivative works on different terms, provided
the original work is properly cited and the use is non-commercial. See: http://
creativecommons.org/licenses/by-nc/3.0/
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BMJ Open: first published as 10.1136/bmjopen-2013-003335 on 19 August 2013. Downloaded from http://bmjopen.bmj.com/ on November 20, 2020 at Helsebiblioteket gir deg tilgang til BMJ.
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